Tobacco Control : Case Study at a California Community College

The 18-24 age group is experiencing a greater increase in smoking prevalence than any other age group in recent years. This article presents a case study of how a California community college successfully implemented a comprehensive tobacco control program to counter pro-tobacco influences, to reduce exposure to secondhand smoke, and to increase the availability of cessation services. The college strengthened the reasonable distance policy by establishing designated smoking areas to the recent adoption of a smoke-free campus. The Student Health Center led the efforts in creating a student coalition, planned advocacy and educational campaigns, developed partnerships with multiple campus departments, implemented an enforcement program, and revised clinical interventions to reflect the US Public Health Service Guidelines. The project was in collaboration with the local health department and two other college campuses. Successful policy change resulted in affecting social norms and a decreased smoking prevalence of 13% in 2000 to 8% in 2004. We encourage other campuses, particularly community colleges, to address tobacco control issues and use some of the strategies presented. © 2005 Californian Journal of Health Promotion. All rights reserved.


Introduction
The tobacco industry has been targeting the 18-24-year-old population, many of whom are in college.According to the California Department of Health Services, this age group is experiencing a greater increase in smoking prevalence more than any other age group in recent years, thus identifying it as a priority population.In 2001, 23.6% of 18-24 year olds reported smoking cigarettes daily (California Department of Health Services, 2003).This group is a major target of and vulnerable to the tobacco industry's advertising campaigns because they are the youngest legal target group, since the Master Settlement Agreement went into effect in 1998.Research also indicates that more than one-fourth of all college smokers begin to smoke regularly at or after age nineteen (Everett & Husten, 1999).
A literature review focusing on smoking policies on college campuses reveals limited published research on this topic, although research on tobacco use and cessation is abundant.A survey of 50 public universities in 2001 reported a low prevalence of recommended tobacco control policies, although the study found strong student support for such policies, even among smokers (Rigotti, Regan, Moran, & Wechsler, 2003).In a survey of student health center directors, the majority of respondents indicate that smoking is a problem or major problem on their campus, making student health centers an ideal place to prevent and curb tobacco use and encourage cessation (Wechsler, Kelley, Seibring, Kuo, & Rigotti, 2001).The American College Health Association's position statement on tobacco use recommends campuses to adopt tobacco/smokefree environments while also supporting the goals of the U.S. Public Health Service to reduce the proportion of adults who smoke to below 12% by the year 2010 (American College Health Association, 2002).
In recent years, research has focused on social smoking among college students as it may prove to be a critical period where students transition to becoming regular smokers (Wechsler, Rigotti, & Gedhll-Hoyt, 1998).Research suggests that having smoking bans in place on college campuses may deter such social smokers from becoming regular smokers (Halperin et. al, 2003).The academic atmosphere provides not only a captive audience but also many natural 'teachable moments' that may impact a young person's decision to prevent or reduce tobacco use.This article presents a case study illustrating strategies a California community college successfully implemented in a comprehensive tobacco control program, including achieving a smoke-free campus and reducing the smoking prevalence of the campus community.

Background
OC is one of the 109 community colleges in California.It is located in Fremont, on the southeast side of the San Francisco Bay Area.The student population is 12,000 with 54% in the targeted 18-24 year age group.The student demographic is reflective of the Bay Area's diverse composition: 41% Asian Pacific Islander, 33% Caucasians, 9% Hispanic, 4% African Americans, 1% Native Americans, and 12% identifying as other.Staff, faculty, and student complaints about environmental tobacco smoke and inquiries about cessation programs served as the impetus for the OC Student Health Center (SHC) to address tobacco control.In 2000, the SHC conducted a campus smoking survey of 449 students, staff, and faculty to assess current smoking prevalence, attitudes, and policy awareness.Survey results indicated a 13% smoking prevalence with more than 50% of smokers indicating an interest in quitting.Eighty percent of respondents believed that secondhand smoke causes lung cancer while 59% expressed interest in campaigns for a smoke-free campus.The SHC also conducted a campus-wide assessment using the California Youth Advocacy Network (CYAN)'s College Advocacy Guide, which includes an inventory of existing tobacco-related policies (e.g., sponsorship, reasonable distance) and key informant interviews.
The campus assessment and attitudes prevalence survey provided the evidence that OC should take advantage of the social climate to address tobacco control comprehensively.We partnered with the Alameda County Public Health Department's Tobacco Control Program (TCP), University of California at Berkeley, and another community college to submit a proposal to the State's Tobacco Control Section competitive grant cycle.We successfully secured four years of funding for the Alameda County 'Students Towards A Rapid Smoke-free School' (STARSS) Project.The grant provided Ohlone College with funding for a part-time Health Educator and a part-time administrative assistant to oversee the project, and provide supplies, educational materials, training costs, and incentive materials for students.The SHC Director / Nurse Practitioner provided overall leadership on an in-kind basis.STARSS's primary objectives are three-fold: 1) to counter pro-tobacco influences with each school conducting one policy advocacy campaign yearly to promote campus or local tobacco-free policies, 2) reduce exposure to secondhand smoke with at least one campus increasing the number of smoke-free common areas by 50-75%, and 3) to increase the availability of cessation services with each student health center adopting the U.S. Public Health Service Guidelines 2000 as part of their clinical policies and protocols.OC successfully achieved all of the objectives and became the one school achieving a smoke-free campus, which affected social norms and decreased the smoking prevalence of 13% in 2000 to 8% in 2004.
At the onset of the program, we discovered that the definition of a smoke-free school varied extensively from campus to campus and by region.OC defined a smoke-free school as one in which smoking is not allowed anywhere on campus with the exception of general parking lots.Our advice to campuses considering achieving this end is to clearly define in the planning stages what smoke-free means in their community.This case study provides an overview of the scope of work: strategies used, challenges encountered, and results of our interventions.We encourage other campuses, particularly community colleges, to address tobacco control issues by replicating some of the strategies used and revise it to reflect the needs and climate of their respective campuses.

Objective #1 -Counter Pro-Tobacco Influences
Countering pro-tobacco influences is an effective way of changing the attitude towards tobacco on campus and creating a new climate and social norm where smoking is unacceptable and inconvenient.The social norms approach to health promotion is the perceived standards of acceptable attitudes and behaviors prevalent among the members of a community.In translating that approach to tobacco control, we need to demoralize smoking and indirectly influence current and potential tobacco users by creating a social climate where tobacco use becomes less desirable, less acceptable, and less accessible.We used survey results to construct social norm messages for campus-wide promotion.Statistics such as "Did you know that 83% of OC students do not smoke?"were posted at locations such as bookstore counters, the library, restrooms, and cafeteria dining tables.

Tobacco Control Student Coalition
The creation of a tobacco control student coalition on campus, called STARSS Club, served as the most powerful vehicle to counter pro-tobacco influences.Recruitment took place year round at events such as new student orientations, club days, and health promotion events (see Appendix A).STARSS Club established official college club recognition in order to gain visibility on campus and a voice in student government in the form of representation in the Inter Club Council (ICC).We created a member's electronic listserv which served as the primary communication method to relay meeting times and events, but also served as an educational resource providing tobacco control articles and website links.Although health center staff assisted in the coordination of club activities and fiscal oversight, students assumed the leadership role in directing its advocacy efforts.

Advocacy and Educational Campaigns
The SHC and STARSS Club collaborated in the planning and implementation of numerous advocacy campaigns and educational activities as part of the comprehensive approach to countering pro-tobacco influences.Participation in national health observances such as the Great American Smoke-out (an annual cessation campaign of the American Cancer Society; see Appendix B) and Kick Butts Day (an annual event of the Campaign for Tobacco-free Kids) took place yearly and are now integrated as part of the campus's outreach events.STARSS Club also worked with various departments such as the campus newspaper and associated students to ensure they took a strong position in declining tobacco industry sponsorship money, and that such positions were documented in their policies and procedure manuals.Other advocacy campaigns urged strengthening of the smoking policy appear later in this case study.

Legislative Visits
STARSS Club members extended their political voice off campus by participating in several legislative visits: the offices of a State Senator and an Assembly member, to advocate for an increase in tobacco tax initiatives and earmarking revenues towards tobacco prevention efforts.Students also used the opportunity to inform the legislators about their proactive work on advancing tobacco control efforts on campus.As a result, the Senator presented the club a letter of support for a smoke-free campus, which served as a powerful tool in securing support from others who hold in high regards opinions from persons of influence.

Objective #2 -To Reduce Exposure To Secondhand Smoke
California is the leader in protecting its residents from exposure to secondhand smoke with the unprecedented passage of the Smoke-free Workplace Law in 1995.According to the California Department of Health Services' recent Field Research poll, evidence indicates that such smoke-free policies not only help protect people from the dangers of secondhand smoke, but the policies also help smokers quit their addiction (California Department of Health Services, 2005).With strong leadership from the state level, the STARSS Project dedicated a great deal of effort to achieving this objective because of the lasting health benefits and widescale impact of reducing secondhand smoke exposure.The advocacy and educational campaigns of the STARSS Project includes four components of the policy change process: the educational campaign on the twenty feet reasonable distance in the first grant cycle year, the campaign to create designated smoking areas in Year Two, the campaign to adopt a smokefree campus in Year Three, and the implementation, education, and enforcement of the new policy in the final year of the project.Additionally, partnership building as one of the most effective strategies is common to the four components.

Reasonable Distance Educational Campaign
At the beginning of the grant cycle, OC smoking policy was a "twenty-feet reasonable distance from buildings, covered corridors, and stairways."Prior to advocating strengthening the policy, we felt the need to first educate the campus community of the existing policy (see Appendix C).Students went around campus and chalked twenty feet lines to illustrate the actual distance.STARSS Club received funding from the student government to purchase Ciggybuttz, a giant cigarette costume used as a media magnet for many of our educational events touring the campus educating students on the policy.We created 'Ciggybuttz Citation Warning' cards with the policy message on the front and smoking cessation information on the backside, which served as great educational tools (see Appendix D).

Advocacy Campaign for Designated Smoking Areas
An advocacy campaign strengthened the smoking policy by creating designated smoking areas began in the Spring Semester of 2002.Abrupt environmental changes seem to impede policy adoption and buy-in from smokers, so we felt strongly about introducing change at reasonable intervals.STARSS Club members conducted a petition signing campaign by making presentations at various clubs and student government meetings, classrooms, and through campus outreach.The campaign lasted one month and collected 561 signatures from people who indicated their support.After garnering the large amount of support, the SHC staff conducted campus observations of locations in which smoking was most frequently taking place.They identified ten campus locations as potential designated areas, based on the following factors: proximity to buildings, level of exposure to nonsmokers, safety, and accessibility (for staff who take smoke breaks).STARSS Club members conducted a designated smoking areas survey in which people ranked their top four preferred choices and provide additional comments.A total of 247 surveys were completed from culturally and academically diverse cross section of the student body.
STARSS Club members presented the petition signatures and designated areas survey results to the Health and Safety Committee, Cabinet, Faculty Senate, Classified Senate, Student Services, and Associated Students.We received overwhelming support from administrators and policymakers because of our approach to involve the campus community in the decision making process.Students also felt empowered when we solicited their opinions and ideas and felt ownership of the development of campus policies.After obtaining support from campus constituents, the College Board of Trustees overwhelmingly approved the policy.

Implementation of Designated Smoking Areas
The four designated areas smoking policy took effect at the start of the 2002 -2003 academic year.Buildings and Grounds department removed old receptacles and took down old policy signs around campus.Grant funds allowed the SHC to purchase 10 new smoking receptacles, four of which were placed in the designated areas and the remaining six were placed at the parking lots near entrances to the campus premise.Promotion of the new policy consisted of many educational strategies (see Appendix E).Proper signage of the new policy was critical: 200 decals were posted on doors and windows of all building and A-frames with the designated smoking areas map printed were placed at high-traffic areas.Promotional materials included printing the policy on napkins for distribution at the coffee stand, cafeteria, and staff lounge; distributing policy postcards to classrooms, the library, and new student orientations; placing keyboard calendars with the policy message in computer labs, and handing out various school supplies with the imprinted policy message.Multiple news articles and opinions pieces about the policy appeared in the campus newspaper.Both the school homepage and health center website contained up-to-date information about the policy and cessation resources.Mass email, campus-wide voicemail, and the road frontage marquees were also effective mediums.In addition, the new policy appeared in several places of the schedule of classes.The campus radio stations aired several public service announcements and the campus TV station worked with STARSS Club members to create a short orientation video highlighting the new policy.
Although we received overwhelming support of the designated smoking areas policy, there were many challenges in opposition from individuals and implementation strategies.During the 2002-2003 academic year, a total of 39 articles, opinion-editorials, and letters to the editors were published regarding both support and opposition to the smoking policy.It was difficult to conduct educational outreach to evening students because of the operating hours of the SHC, its staff, and STARSS club members' schedule.Evening students may also not feel as involved or feel ownership of campus policies because the majority is part time and come on campus exclusively for instruction.
Due to some confusion regarding the designated areas and difficulty of enforcement, going to a smoke-free policy could be easier than a reasonable distance policy.

Advocacy Campaign for a Smoke-free Campus
At the beginning of the 2003 -04 academic year, OC welcomed a new president, a favorable sign for tobacco control advocates because of his stated commitment for advancing the health of the campus.At the start of the school year, the president made an executive decision to eliminate one of the four designated areas due to many complaints from students and staff.The designated area was located in front of the administration building and adjacent to the Health Sciences building.Removing the area had many benefits: respiratory therapy and nursing students were no longer exposed to secondhand smoke that crept through the ventilation system, guests and potential new students walking up to campus to the administration building were welcomed to a more aesthetically pleasant (and healthier) entrance, and removal of one smoking area further restricted accessibility, making it more inconvenient for smokers.
Since the smoking policy issue had heightened awareness at the time, STARSS felt it was appropriate to continue the advocacy towards completely eliminating smoking on campus.The annual end of the year prevalence and attitudes survey also provided the support to do so.Smoking prevalence decreased from 13% to 10%, four out of five survey respondents did not feel inconvenient by the designated areas, and an overwhelming 82% supported making OC a smoke-free campus.Further, three out of four students were aware of the current policy, which indicated that the educational campaigns were effective.Therefore, the STARSS Club and student health center proposed language for a smoke-free campus policy, which stated: "In order to provide a safe and healthy environment for all members of the campus community, smoking is prohibited in all areas of the campus except for general parking lots."The proposed policy also included cessation information availability at SHC and the California State Smoker's Helpline, 1-800-NO-BUTTS.Enforcement language suggestions, including infractions for noncompliance smokers, follow the guidelines for infraction of any education code policy in the community college.

Campus Community Forums
STARSS Club organized a campus community forum for all interested individuals to express their concerns and suggestions for a smoke-free campus policy.Individuals who were not able to attend the forum dropped off comments cards at the SHC.Key presentations were made by the college president, SHC director, and STARSS Club members prior to opening the floor for discussion.Some of the major concerns expressed involved disability access to the parking lots, time sensitivity to reach the parking lots for staff members who take breaks, and enforcement of the policy.

Approval of a Smoke-Free Campus Policy
The process of advocating for a smoke-free campus was seamless during the final stage of policy development because of our consistent record of involving the campus community and the fact that it was student-driven.The proposed policy and comments from the community forums were presented to key decision makers as mentioned earlier and to the Board of Trustees for final approval.The college president made some changes to the proposed language, with the final policy stated as follows: "OC is a designated smoke-free college.Smoking is prohibited in all college vehicles, buildings, indoor and outdoor facilities, handicapped parking and all open areas except for general use parking lots."The policy took effect June 1, 2004, although full implementation was delayed until fall semester resumed, as there are few students on campus during the summer.

Press Conference Announcing the Smoke-Free Campus Policy
A press conference to announce the smoke-free campus policy took place in May 2004, approximately one month before the policy took effect.The SHC staff and STARSS Club members worked with the college's Office of Public Relations and a television production faculty member in planning the event.The Office of Public Relations wrote the press release and solicited feedback from SHC staff.The college president, SHC director, STARSS Club president, and a field representative from our Senator's Office all made short presentations.We proudly displayed a smokefree campus proclamation from the Mayor's Office (see Appendix F), new policy banners, and copies of survey results and newspaper articles supporting the collective efforts.More than fifty faculty, staff, and students attended the event along with eleven media representatives.A total of sixteen articles were published in campus and local media, including two foreign language presses.

Promotion and Implementation of the Smoke-free Campus Policy
Promotion and implementation of the new smoke-free campus policy mirrored the strategies utilized for the designated smoking area policy.While developing support for the new policy, creative strategies emerged.We held a new smoking policy postcard design contest and received many talented artworks.The winning submission resulted in the printing of 5000 postcards for campus-wide distribution (see Appendix G and Appendix H).SHC partnered with the campus bookstore to print bags with the smoking policy on them, which reached an overwhelming majority of students since there is only one location on campus to purchase books, supplies, snacks, and semester parking permits.Placing vinyl banners at highly visible locations around campus and distributing policy postcards to the usual channels as well as Human Resources to new employees contributed to the educational process.We removed smoking receptacles and changed decal wording to reflect the new policy.We also worked with Buildings and Grounds in getting signs painted on the grounds at key entrances to campus.Painted signs that stated "No smoking beyond this point" added visibility for everyone regardless of the entrance used.We used grant funds to purchase the templates, paint, and overtime wage of Buildings and Grounds staff.

People Days Program
From previous studies, research suggests that without enforcement, approaches to tobacco prevention have little effect.Strict enforcement of smoking policies is associated with a decrease in the smoking prevalence.A 2001 study reports that college students' smoking behaviors are only influenced when smoking restrictions reach some threshold levels that make it difficult for smokers to evade these policies (Czartc, Pacular, Chaloupkaf, & Wechsler, 2001).At onset of the project, enforcement was the biggest challenge for the campus.After many discussions with our local constituents, students, staff, administrators, campus safety, buildings and grounds, and other colleges involved in tobacco control, the main barrier to a campus smoking policy change was the ability to initiate and maintain adequate enforcement.STARSS concluded that the policy needed to be student/campus driven.By doing this, all parties could feel ownership of the project and be willing to participate in the implementation.We approached the project as an educational rather than punitive model.We felt that the educational model would act as a form of enforcement without the confrontational consequences.
Out of these discussions, the idea for 100 People/100 Days evolved.The project would begin when students came back to campus for fall semester and would conclude with the Great American Smoke-Out in November with a celebration and campus-wide Fun Run.The model enlisted 100 people from the campus community including students, staff, faculty, and administration.We presented the concept at the fall 2004 Flex Day, a required event for faculty held the two days before a new semester.The presentation included: 1.A brief power point presentation about the history of the project (see Powerpoint 1 or Handout 1). 2. Statistics about how the strengthening of the policy had created a decline of smoking on the campus.3 Enrollment cards for faculty to sign up `to participate in the program for which they would receive 4 flex unit credits for the semester.4. A package that included a T-shirt with "OC is a designated smoke-free campus beginning June 1, 2004" with a request for them to wear them at least 2 times a week for the first 6 weeks and then weekly for the 100 days.5. A pocket size pad with tear off sheets stating the policy on the front and cessation information on the back.6.A whistle reflecting our motto that "OC is Blowing the Whistle On Smoking." 7. A participation certificate to display in their offices.8.A direction sheet on the program how they could help educate the campus about the policy.
We tabled in the campus quad to enlist students and sent out a general campus-wide email asking other members of the staff and campus to participate.All participants received the same packet.We recruited a total of 106 participants.
After enlisting the support of the campus, all participants were emailed a tracking form every two weeks requesting how many tear off sheets they had given out, how many people they had encountered smoking out of the allowed areas, what, if any, problems they encountered and any suggestions for improvement (see Appendix I).
We had a 35% compliance with the forms.Curiously, at the beginning there was strong compliance from smokers but about six weeks into the program there was an increase in disregard for the policy.We thought it might have to do with midterms and stress.As the program progressed, however, there was a marked increase in compliance.We referred any problem areas to Campus Security and they responded and monitored the areas on noncompliance until the problem ceased.
Recruitment continued in the form of tabling in the quad, Interclub Council, and the SHC for six weeks.The plan for repeated offenders was to have students report to the Dean responsible for student discipline, while staff and faculty are to report to Human Resources.There were no referrals made.Finally, we presented tabulated information from the tracking forms to the participants at the end of the project at an appreciation lunch.All attending felt that the program was very effective, were pleased to be included in the program, and many agreed to participate again in the Spring 100 People/100 Days program.After the implementation of the program, the SHC saw a slight increase on the number of students seeking cessation services through the SHC.

Objective #3: To Increase the Availability of Cessation Services
When making environmental tobacco policy changes, it is imperative that smoking cessation be integrated in program planning.The American College Health Association strongly supports colleges offering programs and services that include practical steps to quit using tobacco products.Since the grant project is funded under Proposition 99, the state's tobacco tax initiative, there are some limitations to direct that money towards cessation services, specifically prohibiting the use of providing nicotine replacement therapies (NRTs) to smokers.Instead, our efforts were directed at adopting clinical provider practices and providing educational resources and incentives to smokers.Increasing the availability of cessation services occurred in four strategies: adopting the US Public Health Service Guidelines, providing educational resources and incentives, conducting clinical interventions, and providing referrals to off campus organizations.A campus smoking prevalence survey conducted in June 2003 indicated that approximately half of smokers smoke less than half a pack a day, which does not follow the guidelines for NRTs.
The health center adopted the US Public Health Service Guidelines (Fiore et al., 2000) of conducting the screening and assessment of smokers.A medical assistant or receptionist asks each patient his or her tobacco use status at each visit.Patients who identify as non tobacco-users received a "tobacco-free" label on the front of their chart.This serves as an indication for healthcare providers to conduct positive reinforcement on their decision to be tobaccofree, and to maintain that status.Patients who identified as tobacco-users are handed a 'quit kit'.'Quit kit' packets include an invitation to see a health care provider for consultation, a smoking diary for students to track their use, a contract to set a quit date, the cost of smoking card, and other tobacco education literature.They completed a short questionnaire and we placed the '5 As' encounter form in their chart for the providers to conduct clinical intervention.The short questionnaire asks students how much they smoke, the number of previous quit attempts, and their current level of cessation interest.The '5 As' is a model outlining steps for clinicians to provide treatment of tobacco use and dependence for current smokers: Ask, Advise, Assess, Assist, Arrange.The SHC provides continuous training on implementing the guidelines, while evaluation of the program is discussed at monthly staff meetings.
Given the age group, most smokers will have been smoking for three to ten years and do not have symptoms of tobacco-related disease, resulting in low perception of health vulnerability (Prokhorov, 2003).Additionally, several factors inhibit a student's ability to quit, such as fears of weight gain and the inability to manage stress without nicotine (Ramsay & Hoffmann, 2004).Despite such challenges, clinical interventions play a critical component to curb smoking patterns before it becomes a lifestyle habit.Clinic-based tobacco interventions show a greater public health potential than most other reduction strategies, as smokers say that a healthcare provider's advice to quit is an important motivator to stop smoking (Koonz, 2004).Since more than half of OC students report low cigarette consumption, they are considered low-risk, less dependent smokers.Therefore, encouraging quit attempts by means of the "cold turkey" approach is often used, as well as teaching coping skills and changing habits associated with smoking.
A primary objective in the project's scope of work was that the SHC would increase the number of referrals to the California's Smokers Helpline, the statewide cessation counseling number, by at least 25%.Consequently, we added the counseling number to every piece of material, flyer, poster, and incentive items we created.Cessation information and incentives, such as Smokers Helpline cards, rulers, Pack of Death playing cards were distributed at all of the programs and outreach activities.The SHC also developed its own smoking cessation postcards that are tailored more to the student population.The project also made available to smokers umbrellas with 1-800 NO BUTTS phone number on them for use during rainy days when the 'designated smoking areas' policy was in place.This strategy assisted with compliance on using designated areas and promoting cessation services.The campus newspaper ran cessation ads and the radio station aired public service announcements promoting such services.STARSS members met with staff from disadvantaged programs such as EOPS (Educational Opportunity Programs) and the deaf center to conduct a needs assessment about their specific requirements for cessation materials and services.Additionally, TCP provided periodic updates of cessation classes and support groups in the county, including referrals for NRTs since the health center does not have the means to provide them.

Program Evaluation
The program evaluation efforts, lead by the TCP Director, occurred in various formats.End of the year student surveys on smoking prevalence, attitudes, and policy awareness took place each spring (see Appendix J and Appendix K).The purpose of the survey was to determine the awareness of, the value of, and the intention to comply with current smoking policies of the college.It contained a total of 12 questions, three of which gathered demographic information.For respondents who identified as smokers, they were asked to respond to four additional questions about cessation interests.At the end of the 2003 academic year, we conducted observational surveys to assess the compliance rate of the designated smoking areas over a two-day period.Assessments included the determination of ash receptacles location appropriateness, proper designated area signage, and evidence of smoking activity.We also conducted key informant interviews as part of an ongoing process evaluation with administrators, building and grounds staff, and campus security officers to collect anecdotal information and provide a deeper sense of involvement and ownership of the policy development.
The SHC took an active role in surveying student's smoking habits.The front office staff asks every student if they are smokers.We found that students were more likely to confess to using cigarettes to their peers at the reception desk or the receptionist than the health care provider.If students reply that they do not use cigarettes, the front of their chart is labeled "Tobacco-free".This alerts the health care provider and their first contact with the student after introduction is a positive verbal reward for not using and a brief educational component about being in a high-risk group.If there is no stamp on the front of the chart, the health care provider knows immediately if the student is a smoker and is prepared to counsel the student within the context of the visit using the U.S. Public Health Service 5 A's guidelines (see Appendix L).The student receives one of ten handouts from the University of Pittsburgh Smoking Cessation Program educational kit.At the end of each month, we are able to see the tally of all student smoker encounters on our computerized charting program and compare it to previous months.Although this appears to be a very effective way of direct contact, the OSHC has had poor compliance with cessation efforts.
Further, progress reports, submitted on a quarterly basis to TCP proved to be useful indicators of activities completed and assisted in the strategic mapping of the policy advocacy process.Teleconferences and face-to-face meetings among the three campuses and TCP occurred periodically, providing opportunities for strategy exchange and collaboration efforts.

Discussion
The commitment to make tobacco use an issue of priority is the foundation to a successful comprehensive tobacco control program (see Figure 1).Our greatest asset was the partnerships we have created and nurtured with various groups on campus and in the community over the past four years because tobacco use impacts in health, social, economic, and environmental consequences.Leadership on campus also provided a great deal of support and shared in the vision of creating a smoke-free campus.OCs President identified seven major goals for the college district to work on the next four years in his State of the College Address in fall 2004.One of the goals stated was to "promote and maintain an accessible, clean, safe and healthy college through continuous engagement of students and college personnel in campus preparedness, wellness, beautification and environmental sustainability."The adoption of a smoke-free campus has already contributed to achieving the goal that will result in long last health and environmental benefits, not only on campus, but for individual and population health as well.
At the time of this writing, OC is the fourth California Community College and the only San Francisco bay area college to be 100% smokefree with the exception of parking lots.Being the leader of the pack has been an exciting journey for us.There are few existing programs to learn from because other campuses have not advanced as far in the tobacco control movement.We have been 'inventing the wheel' and hope that other campuses may take some of the strategies and lessons we have learned and tackle tobacco as it is tackling our students and our communities.Although we achieved many successes, we encountered a few challenges along the way.Preemption is an issue that is of concern, particularly to administrators.We were advocating for a stronger policy than the state of California's 20 feet reasonable distance, which was implemented by the Governor in 2003, so questions were raised whether local laws can preempt state laws.Creating the student coalition faced difficulty at the beginning of the campaign.Community college students are typically less involved than their counterparts at state or university campuses because more students work, there is no campus housing, and there is less campus investment given that the college is a place of transition for many.Making meeting times shorter and providing food proved to be excellent incentives for increased student participation.
The time and process of policy advocacy and development were consistent with our progress as well as the readiness of campus to change and adhere.The second year designated smoking areas, however, this presented many challenges in terms of enforcement.Perhaps it may be easier to forego that particular step and advocate for a smoke-free campus immediately.We had a few issues on the proposed scope of work along the way because the public health department staff wrote the majority of the plan, even though we were given ample opportunity for input.It is also difficult to project what kinds of activities and approaches would work from year to year, and from campus to campus, so flexibility and creativity has been key to our success.
We believe our efforts in countering pro-tobacco influences, reducing exposure to secondhand smoke, and increasing the availability of cessation services has positively impacted the OC campus.The campus smoking prevalence of 13% in 2001 decreased to 10% in 2003 and currently stands at 8% (see Figure 2).Process evaluation provided much guidance on improving program and clinic strategies, and we look forward to the impact evaluation of the program at the end of the grant period, June 2005 and several years into the implementation of the smoke-free campus.Further, we provide technical assistance to other college campuses on a continual basis and have presented various components of our program at many college health and tobacco control conferences in the past four years.In agreement with existing literature, we believe that campus smoking restrictions contribute to deterrence of social smoking to habitual smoking, as indicated by the reduction in the overall campus smoking prevalence.daily occasional

Conclusion
The 18-24 age group presents an interesting and important population to work with in reducing tobacco use because of their transition from adolescence to adulthood and because they are increasingly one of the most targeted groups of the tobacco industry.We successfully implemented a comprehensive tobacco control program to counter pro-tobacco influences, reduce exposure to secondhand smoke, and increase the availability of cessation services by making tobacco use an issue of high priority.We achieved our objectives by garnering the support of multiple layers of campus constituents, supporting the student driven coalition in their advocacy efforts, and providing the leadership and vision to the program.We hope this case study will provide motivation and encouragement for other college campuses to prevent, reduce, and eliminate tobacco use and promote smoke-free lives.

Figure 1
Figure 1 Creation of a Smoke-Free Campus Strategic Map Figure 2 OC Smoking Prevalence, 2001 -2004